PPO inpatient admission requests submitted through e-referral could be subject to clinical review

Inpatient acute care admissions for Blue Cross Blue Shield of Michigan commercial PPO members submitted through e-referral could be subject to clinical review, starting in January. It’s a process that our facilities already follow for Medicare Plus Blue^SM PPO inpatient acute care admissions and certain other members.

Clinical reviews support efforts of customers to reduce costs by making sure inpatient admissions are medically necessary. They also help Blue Cross verify that patient stays are appropriate and billed correctly based on diagnosis and condition.

Throughout the year, select facilities must submit medical inpatient stays through e-referral. These stays will be subject to full clinical review from the first day of admission and subject to non-approval by clinical professionals, using InterQual guidelines. Behavioral health authorization requests and clinical reviews will continue according to the current process with the assigned behavioral health management vendor. However, inpatient admission authorization requests processed through New Directions will be subject to full clinical review from the first day of admission and subject to non-approval.

Facilities that will be required to submit full clinical reviews starting Jan. 6, 2020, have been notified. Additional notifications will be sent midyear for the remaining facilities to conduct full clinical reviews starting in October 2020.